Greenville-Pitt County Chamber of Commerce: 2025-2026 Leadership Institute Application

Leadership Institute Application Form - Due by July 25, 2025

Please complete the application form below in its entirety. The information contained in this application is confidential and intended solely for the use of the authorized review personnel.

First & Last Name:
First & Last Name:
Gender:
Gender:
Cell Number:
Cell Number:
Personal Address:
Personal Address:
Preferred Email Address:
Email Address:
Emergency Contact:
Emergency Contact:
Emergency Contact Number:
Emergency Contact #:
Employer/Organization:
Employer:
Job Title:
Job Title:
How long have you been in this role?
Employment Length:
Employer/Organization Address:
Employer Address:
Sponsor Contact:
Sponsor Contact:
Sponsor Contact Number:
Sponsor Number:
Sponsor Contact Email:
Sponsor Email:
How long have you lived in Pitt County?
Years in Pitt County:
Community Involvement:
Please list any community organizations/boards of which you are or have been a member.
Community Involvement:
Personal Achievements:
Please list any personal or professional achievements/accolades.
Achievements:
If selected to participate in the Leadership Institute, what do you hope to gain from this experience?
Goals:
Are there any leadership opportunities/areas of interest within Greenville-Pitt County that you would like to purse?
Leadership Interests:
What are you greatest strengths, and how will they help you contribute to the Leadership Institute?
Strengths:
What do you consider to be the most significant challenges facing Greenville-Pitt County?
Challenges:
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Payment

Credit Card Type

Name on card

Billing address

City / State / ZIP

Card number

Expiration date

Security code

First & Last Name:

Gender:

Cell Number:

Personal Address:

Preferred Email Address:

Emergency Contact:

Emergency Contact Number:

Employer/Organization:

Job Title:

How long have you been in this role?

Employer/Organization Address:

Sponsor Contact:

Sponsor Contact Number:

Sponsor Contact Email:

How long have you lived in Pitt County?

Community Involvement:

Personal Achievements:

If selected to participate in the Leadership Institute, what do you hope to gain from this experience?

Are there any leadership opportunities/areas of interest within Greenville-Pitt County that you would like to purse?

What are you greatest strengths, and how will they help you contribute to the Leadership Institute?

What do you consider to be the most significant challenges facing Greenville-Pitt County?

Payment